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Waste Tire Seft <br /> y & Inspection Repo ;pection Report Number <br /> .G:3➢ State of California _ <br /> CIWMB 181(New 04/04) <br /> California Integrated Waste Management Board <br /> Survey Form - Page 1 i 1 Q 13 0 1 4 1, <br /> Part A- Survey <br /> Business ProfiBLUE OR BLACK INK PEN <br /> le pection Details <br /> TPID- <br /> Site Suffix: Inspection, ` - V lJ p Type (Fill one) <br /> Q Routine Q Re-inspectionReferral <br /> Q Q Observation ! <br /> Localf If Referral,choose referral t <br /> Identifier: ��� / r type(Fill one) <br /> N� Er LC p'+• i Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name - - - <br /> /, -� Inspected By Inspector <br /> 1pour <br /> Physical Address <br /> Street <br /> Inspection Date <br /> City <br /> a e ZIP Code Time In Time Out <br /> Business Rep ---.- <br /> ,.� Title � AM Q AM <br /> O PM QPM <br /> Operational Status ' ire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) ,1 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> (' Active Q Passenger Q Generator 0 Outdoor <br /> GPS Latitude LiA <br /> OQ Closed Q Altered <br /> __1=�._ Q Hauler Q Indoor <br /> _717. I — <br /> uck <br /> Q End-Use Q OTR <br /> Q Container <br /> Longitude Q Inactive Q Ti <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government <br /> Q Retreader Q Dismantler Q Tire Derived Fuel i <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility I ENFORCEM �'" <br /> p ENT STATUS <br /> V , A HAULING AND MANIFEST REQUIREMENTS <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> Q Q PRC§42956-Registration/Decal in Vehicle Compliance Deadline <br /> Q Q 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirementsm / <br /> Q Q 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB Date / <br /> m [1-1 i <br /> Q Q 1:4 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years - - <br /> Q Q 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q Q 1 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q ! Q 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q Q I Other: § Q In Compliance - No Violations <br /> Comments _'. 1 t , _ - —� <br /> i �r 1 11 C , f { t 1 k( v 1 a� <br /> Y r/ <br /> E tt �th.t ff X113 �'r �i` P jt�P <br /> tyakE' 1'1/ _w rl o -.t GI w' y 'fE' G�.Ji` t. f; -/1�t r, r" t <br /> J 'f ! {f( Y1{�' j � 7 z)€ f �'/ f,' <br /> -t r <br /> Inspection Form Included: <br /> Comments Included: Q M <br /> Business Rep's Signature Phone''Number Inspector's Signature <br /> Phone Number <br /> ■ INSTRUCTIONS ON BACK Correct:* Incorrect: X A - <br /> 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />